War wounds that time alone can't heal

Vets who endured the unpeakable often suffering from moral injury

Tom Voss and Anthony Anderson are featured in the documentary "Almost Sunrise," that highlights the issue of moral injury.

Tom Voss and Anthony Anderson are featured in the documentary...

No doubt in the course of your life, you did something, or failed to do something, that left you feeling guilty or ashamed. What if that something was in such violation of your moral compass that you felt unable to forgive yourself, undeserving of happiness, perhaps even unfit to live?

That is the fate of an untold number of servicemen and women who served in Iraq, Afghanistan, Vietnam and other wars. Many participated in, witnessed or were unable to help in the face of atrocities, from failing to aid an injured person to killing a child, by accident or in self-defense.

For some veterans, this leaves emotional wounds that time refuses to heal. It radically changes them and how they deal with the world. It has a name: moral injury. Unlike a better known casualty of war, post-traumatic stress disorder, or PTSD, moral injury is not yet a recognized psychiatric diagnosis, although the harm it inflicts is as bad if not worse.

The problem is highlighted in a new documentary called "Almost Sunrise," which will be shown next weekend at the Human Rights Watch Film Festival in New York and on June 23-24 at AFI Docs in Washington. The film depicts the emotional agony and self-destructive aftermath of moral injury and follows two sufferers along a path that alleviates their psychic distress and offers hope for eventual recovery.

Therapists within and outside the Department of Veterans Affairs increasingly recognize moral injury as the reason so many returning vets are self-destructive and are not helped, or only partly helped, by established treatments for PTSD.

Moral injury has some of the symptoms of PTSD, especially anger, depression, anxiety, nightmares, insomnia and self-medication with drugs or alcohol. And it may benefit from some of the same treatments. But moral injury has an added burden of guilt, grief, shame, regret, sorrow and alienation that requires a very different approach to reach the core of a sufferer's psyche.

Unlike the soldiers who were drafted to serve in Vietnam, the members of the armed forces today chose to enlist. Those deployed to Iraq thought at first they were fighting to bring democracy to the country, then were told later it was to win hearts and minds. But to many of those in battle, the real effect was "to terrorize people," as one veteran says in the film.

That war can be morally compromising is not a new idea and has been true in every war. But the therapeutic community is only now becoming aware of the dimensions of moral injury and how it can be treated.

Thomas Keating, a founding member of Contemplative Outreach, says in the film, "Antidepressants don't reach the depth of what these men are feeling," that they did something terribly wrong and don't know if they can be forgiven.

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The first challenge, though, is to get emotionally damaged veterans to acknowledge their hidden agony and seek professional help instead of trying to suppress it, often by engaging in self-destructive behaviors.

The second challenge is to win their trust, to reassure them that they will not be judged and are deserving of forgiveness.

Therapists who study and treat moral injury have found that no amount of medication can relieve the pain of trying to live with an unbearable moral burden. They say those suffering from moral injury contribute significantly to the horrific toll of suicide among returning vets - estimated as high as 18 to 22 a day in the United States, more than the number lost in combat.

The film features two very troubled veterans of the war in Iraq, Tom Voss and Anthony Anderson, who decide to walk from Milwaukee to Los Angeles - 2,700 miles taking 155 days - to help them heal from the combat experiences that haunt them and threaten to destroy their most valued relationships. Six years after returning from his second deployment in Iraq, Voss said of his mental state before taking the cross-country trek, "If anything, it's worse now."

Along the way, the two men raise awareness of the unrelenting pain of moral injury many vets face and encourage them to seek treatment. Voss and Anderson were helped by a number of counselors and treatments, including a Native American spiritual healer and a meditative technique called power breathing. They also found communing with nature to be restorative.